CANADIAN MEDICAL ASSOCIATION

CODE OF ETHICS

1965

Transcribed from the original by

A Keith W Brownell MD, FRCPC and Elizabeth “Libby” Brownell RN, BA

April 2001

INTERNATIONAL CODE OF MEDICAL ETHICS OF THE WORLD MEDICAL ASSOCIATION

Duties of Doctors in General 1. A DOCTOR MUST always maintain the highest standards of professional conduct. 2. A DOCTOR MUST NOT allow himself to be influenced merely by motives of profit. 3. THE FOLLOWING PRACTICES ARE DEEMED unethical: 4. a. Any self advertisement except such as is expressly authorized by the national code of medical ethics. 5. b. Taking part in any plan of medical care in which the doctor does not have professional independence. 6. c. To receive any money in connection with services rendered to a patient other than the acceptance of a proper professional fee, or to pay any money in the same circumstances without the knowledge of the patient. 7. UNDER NO CIRCUMSTANCES is a doctor permitted to do anything that would weaken the physical or mental resistance of a human being except from strictly therapeutic or prophylactic indications imposed in the interest of the patient. 8. A DOCTOR IS ADVISED to use great caution in publishing discoveries. The same applies to methods of treatment whose value is not recognized by the profession. 9. WHEN A DOCTOR IS CALLED UPON to give evidence or a certificate he should only state that which he can verify.

Duties of Doctors to the Sick 10. A DOCTOR MUST always bear in mind the importance of preserving human life. 11. A DOCTOR OWES to his patient complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond his capacity he should summon another doctor who has the necessary ability. 12. A DOCTOR OWES to his patient absolute secrecy on all which has been confided to him or which he knows because of the confidence entrusted to him. 13. A DOCTOR MUST GIVE the necessary treatment in emergency, unless he is assured that it can and will be given by others.

Duties of Doctors to Each Other 14. A DOCTOR OUGHT to behave to his colleagues as he would have them behave to him. 15. A DOCTOR MUST NOT entice patients from his colleagues. 16. A DOCTOR MUST OBSERVE the principles of ‘The Declaration of Geneva’ approved by The World Medical Association.

1965. A (April 21, 2001) 1 CODE OF ETHICS

“He should be modest, sober, patient, prompt to do his whole duty without anxiety; pious without going so far as superstition; conducting himself with propriety in his profession, and in all the actions of his life.” – Hippocrates.

Introductory

“As ye would that men should to do you, do ye even so to them,” is a Golden Rule for all men. A Code of Ethics for can only amplify or focus this and other golden rules and precepts to the special relations of practice. As a stream cannot rise above its source, so a code cannot change a low-grade man into a high-grade doctor, but it can help a good man to be a better man and a more enlightened doctor. It can quicken and inform a conscience, but not create one. Only in a few things can it decree ‘thou shalt’ or ‘thou shalt not’, but in many things it can urge ‘thou shouldst’, or ‘thou shouldst not’.

While the highest service they can give to humanity is the only worth-while aim for those of any profession, it is so in a special sense for physicians, since their services concern immediately and directly the health of the bodies and minds of men.

Of the Duties of Physicians to Their Patients

For the honourable the first consideration will always be the welfare of the sick. On his conscience rest the comfort, the health and the lives of those under his care. To each he gives his utmost in science and art and human helpfulness. Their confidences are safe in his keeping, except in those rare instances when the safe-guarding of society imposes a higher law and except when the physician is performing a service to his patient by submitting necessary information to a third party with the consent of the patient or a responsible relative or guardian. He does not multiply costs without need, nor raise needless fears, nor allay fears without full consideration. Even when he cannot cure he will alleviate, and be counselor and friend.

It is a special duty for one who stands guard over the lives of men to keep his art and his science in good repair, to enlarge and refresh his knowledge constantly, and to give his patients treatment that is not only sympathetic, but the best possible in the circumstances. To this end he will be ever anxious, by reading and postgraduate training, to keep abreast of modern advances in ; and also he will always be willing to check and supplement his diagnosis, treatment and prognosis by consultation. No excellence in one respect can excuse slipshod, ignorant or out-dated service.

Every physician should practice the art as well as the science of medicine. To this end every patient is entitled to a careful history and a thorough physical

1965. A (April 21, 2001) 2 examination as well as having made available all the procurable aids that science has developed for use in diagnosis and treatment, whenever in the judgment of his physician these are indicated.

In short, let it be said once again that the greatest well-being of the sick person should be the whole study and care of the honourable physician.

“The greatest trust between man and man is the trust of giving counsel.” - Francis Bacon.

Of the Duties of Physicians Regarding Consultations

It is the duty of the attending physician to accept the opportunity of a second opinion in any illness that is serious, obscure or difficult, or when consultation is desired by the patient or by persons authorized to act on the patient’s behalf. While the physician should name the consultant he prefers, he should not refuse to meet the physician of the patient’s choice, though he may urge, if he so thinks, that such consultant has not the qualifications or experience that the existing situation demands.

In the following circumstances, it is particularly desirable that the attending physician, while dealing with an emergency when this exists, should, whenever possible, secure consultation with a colleague: a. When the propriety of performing an operation or of adopting a course of treatment which may entail considerable risk to the life, activities or capacities of the patient has to be considered, and particularly when the condition which it is sought to relive by this treatment is in itself not dangerous to life. b. When operative measures involving the death of the foetus or an unborn child are contemplated, particularly if labour has not begun. c. When there are grounds for suspecting that the patient i. Has been subjected to an illegal operation, or ii. Is the victim of criminal poisoning.

Since consultation is planned wholly for the good of the sick person, there should enter into it no trace of insincerity, rivalry or envy. The attending physician and the consultant may examine the patient together or the consultant may examine the patient alone. The attending physician should, as a rule, give the consultant a brief oral or written history of the case before he examines the patient. If possible, the attending physician and consultant should discuss the case in private, and the consultant should record his opinion either on the records and/or by closed letter addressed to the attending physician. Their joint decision should be communicated to the patient and his family by the attending physician, supplemented, if necessary, by the consultant. If agreement as to

1965. A (April 21, 2001) 3 diagnosis and treatment is not possible, and if either doctor is convinced that the future well-being of the patient is concerned is in jeopardy, a further opinion should be sought and the patient and/or the family should be informed of this by the attending physician, and the necessity for such action also explained.

If the attending physician should retire from the case, the consultant should not replace him during the present illness, except at the request of the attending physician or with his approval.

Patients Referred to Physicians or Sent to

When a patient has been sent either for office examination and treatment or admission to a hospital under the consultant’s care, it is the duty of the consultant to report findings and discuss them with the attending physician so that the latter may have all possible advantage from the consultation. It is equally the duty of the physician referring a patient to give as full information as possible to the consultant. At the conclusion of the examination and treatment by the consultant the patient should be referred back to the attending physician with an adequate report.

The Induction of Abortion

The induction or procuring of abortion involves the destruction of life. It is a violation both of the moral law and of the criminal code of Canada, except when there is justification for its performance. The only justification is that the continuance of pregnancy would imperil the life of the mother. It is appreciated, however, that there are certain faiths which, on religious grounds, do not recognize this exception. Such an operation should never be undertaken unless the attending physician and consultant agree as to the necessity for such action; the consultant must be a physician in good standing and his recommendation should be put in writing. Where hospital facilities are available the operation should be performed in a hospital, and, in such case, the superintendent or head of the institution should be notified in advance.

Sterilization

Without reference to the legal aspects, sterilization is ethical when carried out for valid reasons. The operation should only be performed after adequate corroborative medical consultation. The operation should not be performed against professed religious or moral convictions of the patient or a legal guardian. Neither should sterilization be performed

1965. A (April 21, 2001) 4 against the professed or moral convictions of any hospital administration or medical personnel directly involved.

A Physician as Visitor

When a physician, as a personal friend, meets the patient of another physician, or calls upon him when ill, he must be careful not to be drawn into interference through suggestions or opinions. These should never be expressed except when he has been called in consultation in the authorized way.

“Let him be tender with the sick, honourable to men of his calling.” --- Ambrose Pare.

Of the Duties of the Individual Physician to the Profession at Large

The physician should be jealous for the honour of his craft, for its devotion to truth and the high quality of its service to mankind. No profession or calling should demand higher standards of integrity or more constant devotion to the common good. “I hold every man a debtor to his profession.” - Francis Bacon.

Of Professional Services of Physicians to Each Other

It is unwise for a physician to treat himself or members of his household in any serious illness when the services of another physician are available.

If in such illnesses, whether because of friendship or to give advantages of special skill or experience, several members of the profession visit the sick physician or dependent, it must be made clear that some one designated physician has definite responsibility for the carrying on of the treatment.

Where a physician enrolls himself and/or the members of his family with an insurance carrier or a prepaid medical plan for the payment of accounts for medical or surgical services rendered to himself and/or the members of his family, it should not be considered unethical for the attending physician or surgeon to submit accounts for services rendered to the insurance carrier or prepaid medical plan.

Paid Advocacy

1965. A (April 21, 2001) 5 The paid advocacy of any commodity whatever its merits, cannot be reconciled with the ideals of a physician. He must be free to choose from all elements those best for his patient, and not be a merchandiser pushing one particular element for gain. It is precisely because he is a physician that his advocacy has extra market value. In thus advertising a commodity, he presumes to sell that which is not his to sell, the common tradition and inheritance of reputation, esteem and standing of the whole profession.

Fees and Commissions

The only basis on which a fee may be charged to a patient, or on which money may be received by any medical practitioner, is that of work actually done for the patient, and such patient must receive a direct statement from the medical practitioner concerned. Any other arrangement between two or more medical practitioners, whereby one receives part of the fee paid to the other practitioner, is unethical and may contribute to dishonesty.

In cases where in the opinion of the attending medical practitioner the services of one or more consultants are required, each such consultant shall render his account and submit his receipt individually.

Each practitioner should send his account to the patient individually, provided however that a surgeon who has a regular assistant at operations may pay him directly. When the assistant has referred the patient to the operating surgeon, the assistant should send a statement of his fee directly to the patient.

If fees are collected by an organized , medical group, medical partnership or medical practitioner employing regular assistants, each such organization is in effect regarded as an individual who acts in that capacity. A completely itemized account should be submitted to the patient, or his agent, listing each individual doctor’s services and charges. Notwithstanding the generality of the foregoing, it is considered ethical for more than one member of an organized clinic, medical group, medical partnership, or medical practitioner and his assistant or assistants, to charge for necessary services rendered to the patient.

When a third person or organization enters into a financial arrangement between medical practitioner and patient, each medical practitioner should render an individual account to the third person or organization concerned; if more than one medical practitioner is carrying out professional services, a statement to the patient by the third person or organization should show the amount paid to each physician.

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It is highly desirable for a physician to adhere strictly to the practice of his profession, disassociating himself entirely from the dispensing of all commodities relating to the practice of medicine and the profits derived therefrom. In places where those with special training or qualifications are not available, dispensing of such commodities may be undertaken.

The physician’s statement to the patient should show clearly and separately his professional fee, and the charge for the commodity dispensed.

It is undesirable that medical practitioners should have a proprietary interest in preparations or appliances which it may be their duty to recommend to patients.

Where physicians, a medical group or clinic, own and occupy an office building, it should not be considered unethical for them to rent space to businesses or individuals under the following provisions: 1. That the rent charged is the normal or going rent for that or similar space. 2. That there is neither real nor implied endorsation of the business carried on by the tenant. 3. That other than normal rent, there be no profit of any kind, direct or hidden, derived from the tenant concerned.

Standards of Fees

General rules and standards regarding fees should be adopted by the profession in each province and district. It should be deemed a point of honour among physicians to adhere to these standards with as much uniformity as varying conditions admit.

Medical Associations

A physician should associate himself with local, provincial and Canadian medical organizations to promote both his own and the general advancement in our science and art.

Advertising

The word ‘advertising’ in relation to the medical profession must be taken in its broadest sense. It includes all those methods by which a practicing physician is made known to the public, either by himself or by others without his objection, in a manner which can be fairly regarded as

1965. A (April 21, 2001) 7 having for its purpose the obtaining of patients or the promotion in other ways of the physician’s individual professional advantage.

Excepting a plain card which conforms to local usages, any form of advertising is unprofessional for the practicing physician. Practice should not be gathered by any kind of solicitation, direct or indirect. The best advertisement of a physician is a well-merited reputation for ability and probity in his profession.

However, the following are acceptable practices: a. It is proper for a doctor when he enters practice, changes his type of practice, or moves to a new location, to indicate this in a card sent to other practitioners; b. If he is entering group practice with other physicians in the same type of practice, it would be proper for their names to be listed on the card, along with the name of the group; c. It would not be proper to list persons in other types of practice; It would be proper for a doctor whose practice is being taken over to send to his former patients a card notifying them of the take-over.

Advertising may be very insidious. A physician should not procure, sanction, be associated with or acquiesce in, notices which commend his own or any physician’s skill, knowledge, services and qualifications, or which deprecate those of others.

An honourable physician will never be guilty either of boasting of cures, or of promising radical cures, or of self-praise in order to gather practice.

Communications to the Laity on Medical Subjects

All opinions on medical subjects which are communicated to the laity by any medium, whether it be a public meeting, the lay press, radio or television should be presented as from some organized and recognized medical society or association and not from an individual physician. Such opinions should represent what is the generally accepted opinion of the medical profession.

When an official body of organized medicine finds it necessary to ask a medical practitioner to make a statement for the public and decides that the circumstances make it necessary that his name be attached to it, the medical practitioner shall be absolved from criticism in so doing.

A physician acting in a public capacity, e.g., a Health Officer, may issue to the public warnings or notices regarding public health matters under his own name.

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Radio Broadcasting

It is legitimate and even desirable that topics relating both to medical science and policy and to public health and welfare should be discussed by physicians who can speak with authority on the question at issue. In any medium of discussion, but especially in radio broadcasting, because of its vast range, it is essential that the physician who takes part should avoid methods which tend to his personal professional advantage. Not only should he personally observe this rule, but he should take care that the announcer in introducing him makes no laudatory comments and no unnecessary display of the physician’s medical qualifications and appointments. There is a special claim that physicians of established position and authority should observe these conditions, for their example must necessarily influence the action of their less recognized colleagues. These remarks apply particularly to practising physicians. A physician serving in a public capacity is in a different position but even he should see to it that it is his office, rather than himself, that is exalted. “Live by the old ethics and the classical rules of honesty.” - Sir Thomas Browne.

Discoveries

No advance or discovery in any branch of medical science made by a physician should ever be capitalized or marketed by him in any way for his personal gain, or kept secret for his private advantage. Such advance or discovery should be made common for the advantage of the whole profession, and for the progress of science. There are well recognized methods by which physicians can place their work and discoveries before those who are fitted by education and experience to judge them. The lay press is not the proper medium for the first announcement of a physician’s work or discoveries.

Group Practice and Ethics

Whatever is right and becoming in a physician is equally right for any association of physicians in or other groups, and whatever is obligatory upon the individual is equally obligatory upon the group.

It is undesirable and not in keeping with the principles of the medical profession for medical practitioners to practise medicine in partnership with anyone not duly registered to practise medicine.

1965. A (April 21, 2001) 9 Emergency Calls

When a physician is called in the absence of the attending physician, or in emergency, he will, on arrival of the attending physician, hand over all care and responsibility, and retire from the case.

In a case of sudden illness or accident when several physicians are called, the first to arrive should be considered to be in charge. However, he should withdraw in favour of the regular family attendant should he arrive, or of any other physician preferred by the patient.

Locum Tenency and Assistantships

A physician who has been locum tenens or an assistant to another physician, especially in a rural district or a small town, should not begin practice in the same neighbourhood except with the written consent of the practitioner for whom he has substituted or to whom he has been an assistant.

Where a physician is contemplating locum tenency or an assistantship to another physician, there should on all occasions be a written contract between the physicians concerned so that there will be no misunderstanding as to where and when the locum tenens or assistant may commence practice on the completion of his contract or period of employment.

Forms and Certificates

The attention of all members of the medical profession is drawn to Section 12 of the International Code of Medical Ethics of the World Medical Association as printed in the prologue to this Code of Ethics on page 2. This section reads as follows: “A doctor owes to his patient absolute secrecy on all which has been confided to him or which he knows because of the confidence entrusted to him.”

Therefore, in all forms where medical reports are to be filled in by physicians there should be included a declaration to be signed by the patient or a responsible relative or guardian stating that assent is given to the physician to supply the information requested. It is also strongly recommended that these forms and/or declarations be supplied in duplicate to permit the physician to retain a carbon copy.

Contract Practice

1965. A (April 21, 2001) 10 While not in itself unethical, contract practice becomes so if there is solicitation for patients, underbidding, interference with the choice of physician, or if the compensation is so low that adequate service cannot be given, or if professional services are made to yield profits to controlling lay groups.

Differences Between Physicians

“I prefer to attribute high motives to my friends’ acts.” - Pasteur.

Differences between physicians which after fair discussion cannot be adjusted should be referred to the appropriate authority. Complaints of unprofessional conduct should be referred in writing to the Registrar of the provincial medical licensing authority.

Medical Witnesses

The medical witness should be actuated by a desire to assist the court in arriving at a just decision and not merely to further the interests of the party on whose behalf he has been summoned.

Patent Preparations

A physician should not make use of, or recommend, any remedy, the principal ingredients of which are not disclosed to the profession.

Succeeding Another Physician

A physician is not free to assume care of a patient who has had another attendant in the current illness, unless he has satisfied himself that those responsible have notified the other physician that his services are no longer required.

Care in Comment

When one physician succeeds another in the care of a patient he should make no adverse comment upon the treatment already given.

Of the Relations of Physicians In and With Hospitals

Mutual understanding and co-operation between the medical profession and Boards of Management of hospitals are most essential.

Membership in an honorary attending staff carries with it certain general responsibilities such as teaching and enlarging medical knowledge. Such a position should be held as a trust for the good of the

1965. A (April 21, 2001) 11 community and of the medical profession. All members should make their contribution to the work required for the maintenance of high standards of hospital care.

A physician may rightly apply for such a position but should not canvass for it.

On appointment members of the honorary attending staffs should have no misunderstanding as to their terms of service. They should not provide medical services without charge to those patients who are financially capable of paying for their treatment but should freely and gladly provide all necessary medical services to those indigent patients who are a responsibility of the medical staff.

Nurses and Nursing

The services provided by the nursing profession in the care and prevention of illness are essential and complementary to the work of the medical profession. Therefore, it is the duty of all doctors to support and, where necessary, guide the work of nurses to the end that both professions, while remaining true to their respective codes of ethics, will so cooperate as a harmonious team that there will be provided an optimal service to all patients under their care.

GENERAL CONCLUSION

“ …. the physician both individually and collectively should constantly confront his ideas and actions not only with the criticism of his own conscience but also with the sentiments of the world whose servant he is. He should never forget that his private conscience and that of the world are interwoven inseparably. Like religion in its manifold forms medicine comprises in its ethics the experience of and aspirations towards highest humanity, reflections of divine love. Hence medical ethics have contributed to the introduction of humanistic elements in our society; hence medical ethics also determine the general aspect and the conscience of culture.” - Professor G.C. Heringa, Netherlands.

The corollary of these words is that the complete physician is not a man apart and cannot content himself with the practice of medicine alone, but should make his contribution, as does any other good citizen, towards the well-being and betterment of the community in which he lives.

The Oath of Hippocrates 460 – 370 B.C.

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“I SWEAR by Apollo Physician, by Aesculapius, by Health, by Panacea and by all the gods and goddesses, making then my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture. To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else. I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly, I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein. Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me.”

The Prayer of Maimonides (in part) 1135 – 1204 A.D.

Almighty God! With infinite wisdom hast Thou shaped the body of man. Ten thousand times ten thousand organs hast Thou put within it that move in harmony and without ceasing to keep in all its beauty the whole – the body, the envelope of the immortal soul….

To man hast Thou given the wisdom to soothe his brother’s sufferings, to know his disorders, to extract what substances may heal, to learn their powers, and prepare and use them suitably for every ill ….

Inspire in me a love for my Art and for Thy creatures. Let no thirst for profit or seeking for renown or admiration take away from my calling … Keep within me strength of body and of soul, ever ready, with cheerfulness, to help and succour rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being.

If those should wish to improve and instruct me who are wiser than I, let my soul gladly follow their guidance; for vast is the scope of our Art.

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In all things let me be content, in all but the great Science of my calling. Let the thought never arise that I have attained to enough knowledge, but vouchsafe to me ever the strength, the leisure and the eagerness to add to what I know. For Art is great, and the mind of man is ever growing.

Almighty God! In Thy mercy Thou hast chosen me to watch beside life and death in Thy creatures. I now go to the work of my calling. In its high duties sustain me, so that it may bring benefit to mankind, for nothing, not even the least can flourish without Thy help.

The Declaration of Geneva Adopted by the General Assembly of the World Medical Association at Geneva, Switzerland, September, 1948.

AT THE TIME OF BEING ADMITTED AS MEMBER OF THE MEDICAL PROFESSION:

I SOLEMLY PLEDGE myself to consecrate my life to the service of humanity;

I WILL GIVE to my teachers the respect and gratitude which is their due;

I WILL PRACTISE my profession with conscience and dignity;

THE HEALTH OF MY PATIENT will be my first consideration;

I WILL RESPECT the secrets which are confided in me;

I WILL MAINTAIN by all the means in my power the honour and the noble traditions of the medical profession;

MY COLLEAGUES will be my brothers;

I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

I WILL MAINTAIN the utmost respect for human life, from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity.

I MAKE THESE PROMISES solemnly, freely and upon my honour.

1965. A (April 21, 2001) 14